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Background:  Late antenatal care (ANC)-seeking among pregnant adolescents threatens their health outcomes, and the health outcomes of their new-borns. South Africa has experienced a rapid increase in adolescent pregnancies during the COVID-19 pandemic, adding to the existing concerns around adolescent pregnancy care-seeking behaviour., Aim:  The main aim of this study was to investigate the causes and covariates of late ANC access among adolescents in the Cape Town Metropole, South Africa., Setting:  Three public healthcare facilities in the Cape Town Metropole, 2018-2019., Methods:  A retrospective, cross-sectional study on ANC seeking behaviour was conducted, surveying 202 adolescents. Late attendance was defined as attending ≥ 3 months. For this study, adolescents were defined as women aged 16-18 years. The sample was restricted to adolescents who used public healthcare facilities or who did not attend at all. Data were analysed using univariate, bivariate and multivariate methods., Results:  A total of 50.8% (n = 99/195) of the pregnant adolescents in the sample had their first ANC visit 3 months. 14.9% (n = 29/195) did not attend at all. Major contributors to delayed care-seeking include poor pregnancy identification (n = 45/99, 45.5%), and a lack of information about ANC. Age, education, and alcohol consumption were significant predictors of delayed care-seeking., Conclusion:  Delayed ANC attendance contributes to negative long-term health outcomes for pregnant adolescents and their new-borns. Improving access to pregnancy tests in the public sector could benefit adolescents with earlier pregnancy identification. Adolescents need to be made aware of their care seeking options.Contribution: There is evidence of long-term health impacts of late ANC attendance by pregnant adolescents, but there is an absence of evidence on the timing and barriers of late care-seeking behaviour. In this study, late ANC attendance among adolescents was associated with late pregnancy identification and poor knowledge of care options.

Antenatal care is vital in improving pregnancy outcomes. It is a vehicle for assisting in the reduction of maternal mortality. For this to be realized, there is a need for antenatal care that is effective, acceptable, and accessible to the users. However, South Africa is faced with challenges that impact the utilization of the service. A descriptive phenomenological design was used to explore the challenges of pregnant women attending antenatal care at selected facilities in Gauteng Province. Data were collected from 14 purposefully selected participants through in-depth individual telephonic interviews. Data analysis was guided by the Colaizzi steps. Credibility, dependability, confirmability, and transferability measures were applied to ensure trustworthiness. Ethical principles were adhered to throughout the study. Three themes emerged: resources and Covid-19-related challenges, overwhelming logistical processes, and suggested recommendations for ANC improvement. Management should provide sufficient resources and counselling services for staff and prioritize antenatal care services.

Background: Antenatal care (ANC) provides healthcare services to pregnant women in an attempt to ensure, the best possible pregnancy outcome for women and their babies. Healthcare providers' understanding of their patient's behaviour and reasons for engagement in care and their response to this insight can influence patient-provider interactions and patient demand for ANC early in pregnancy. We examined the insight of healthcare providers into women's reasons for starting ANC later than the South African National Department of Health's recommended 20 weeks gestation. We also looked at the impact of late ANC presentation on overall healthcare providers' work experiences and their response in their interactions with patients., Methods: In-depth interviews were conducted with 10 healthcare providers at Maternal Obstetrics Units (MOU) and Primary Healthcare Centres (PHC) in Gauteng, South Africa. Healthcare providers were selected with the assistance of the facility managers. Data analysis was conducted using the qualitative analysis software NVivo 11, using a thematic approach of pinpointing, examining, and recording patterns within the data., Results: Healthcare providers were aware of patients need for secrecy in the early stages of pregnancy because of fears of miscarriage and women's preference for traditional care. Women with prior pregnancies presumed to know about stages of pregnancy and neglected to initiate ANC early. Barriers to early ANC initiation also include, women's need to balance income generating activities; travel cost to the clinic and refusal of care for coming after the daily patient limit has been reached. Healthcare providers encounter negative attitudes from un-booked patients. This has a reciprocal effect whereby this experience impacts on whether healthcare providers will react with empathy or frustration., Conclusions: Timing of ANC is influenced by the complex decisions women make during pregnancy, starting from accepting the pregnancy itself to acknowledging the need for ANC. To positively influence this decision making for the benefit of early ANC, barriers such as lack of knowledge should be addressed prior to pregnancy through awareness programmes. The relationship between healthcare providers and women should be emphasized when training healthcare providers and considered as an important factor that can affect the timing of ANC.

Background: Late presentation combined with limited engagement in antenatal care (ANC) increases risk of vertical transmission among mothers living with HIV. Female sex workers (FSW) have more than four times greater burden of HIV than other women of reproductive age in South Africa and the majority of FSW are mothers. For mothers who sell sex and are at increased HIV acquisition risk, timely and routine ANC seeking is especially vital for prevention of vertical transmission. This study represents a mixed-methods study with FSW in Port Elizabeth, South Africa, to characterize factors influencing ANC seeking behaviors in a high HIV prevalence context., Methods: FSW (n = 410) were recruited into a cross-sectional study through respondent-driven sampling between October 2014 and April 2015 and tested for HIV and pregnancy. A sub-sample of pregnant and postpartum women (n = 30) were invited to participate in in-depth interviews (IDIs) to explore their current or most recent pregnancy experiences. IDIs were coded using a modified grounded theory approach and descriptive analyses assessed the frequency of themes explored in the qualitative analysis among the quantitative sample., Results: In the quantitative survey, 77% of FSW were mothers (313/410); of these, two-thirds were living with HIV (212/313) and 40% reported being on antiretroviral therapy (ART) (84/212). FSW in the qualitative sub-sample reported unintended pregnancies with clients due to inconsistent contraceptive use; many reported discovering their unintended pregnancies between 4 and 7 months of gestation. FSW attributed delayed ANC seeking and ART initiation in the second or third trimesters to late pregnancy detection. Other factors limiting engagement in ANC included substance and alcohol use and discontent with previous healthcare-related experiences., Conclusions: Late pregnancy discovery, primarily because pregnancies were unplanned, contributed to late ANC presentation and delayed ART initiation, increasing risks of vertical HIV transmission. Given limited ART coverage among participants, addressing the broader sexual and reproductive health and rights needs of mothers who sell sex has important implications for preventing vertical transmission of HIV. Integrating comprehensive family planning services into FSW programming, as well as providing active linkage to ANC services may reduce barriers to accessing timely ANC, decreasing risks of vertical transmission.

Objectives One of the factors linked to South Africa's relatively high maternal mortality ratio is late utilization of antenatal care (ANC). Early utilization is especially important in South Africa due to the high HIV prevalence amongst pregnant women. This study examined the impact of a package intervention, consisting of an incentive called the Thula Baba Box (TBB) and a community health worker (CHW) programme, on early utilization of ANC. Methods A pilot randomised controlled trial consisting of 72 women aged 18 and older was conducted in an urban area in South Africa to evaluate the impact of the package intervention. Women were recruited and randomised into either intervention (n = 39) or control group (n = 33). The intervention group received both the TBB and monthly CHW visits, while the control group followed standard clinical practice. Both groups were interviewed at recruitment and once again after giving birth. The outcomes measured are the timing of first ANC visit and whether they attended more than four times. It is anticipated that the box will also have a beneficial impact on infant health outcomes, but these fall out of the scope of this study. Results Women in the intervention groups sought care on average 1.35 months earlier than the control group. They were also significantly more likely to attend at least four antenatal clinic visits. Conclusions for practice Given the South African context and the importance of early care-seeking behaviour to improve health outcomes of HIV-positive pregnant women, the intervention can help to improve maternal and neonatal health outcomes. Further research is needed to investigate the impact of the two interventions separately, and to see if these findings hold in other communities.

Objectives The objective of this study was to investigate the causes and covariates of late antenatal care access in South Africa. Methods A cross-sectional study was conducted, interviewing 221 women at four public-sector labour wards in Cape Town, South Africa in 2014. A definition of late attendance as attending ≥ 5 months was used. Data were analysed using univariate, bivariate and multivariate methods. Results Of the women who attended antenatal care at a public-sector clinic (n = 213, 96.4%), more than half (51.2%) attended ≥ 3 months and < 5 months, and a quarter (26.3%) attended ≥ 5 months. For those attending ≥ 5 months, 51.8% cited late recognition of pregnancy as the major reason for delayed attendance. Supply-side barriers were not identified as large contributing factors to delayed attendance. Late antenatal care access was predominantly associated with demand-side factors. Women who accessed antenatal care ≥ 5 months were more likely to be in the poorest 40% of the wealth-index distribution (p = 0.034) and to not have completed high school (p = 0.006). They were also more likely to report alcohol consumption during pregnancy (p = 0.020) and be multiparous (p = 0.035). Having completed high school was protective of late antenatal care access in stepwise logistic regression analysis (OR 0.403, CI 0.210-0.773, p < 0.01). For women who attended ≥ 3 months, late access was associated with unwanted pregnancy (p = 0.030). Conclusions for Practice Improved access to pregnancy tests could assist in earlier pregnancy identification. Interventions to increase awareness of the importance of early antenatal care attendance among vulnerable women may help.

Effective prevention of mother-to-child transmission benefits from early presentation to antenatal care (ANC). It is, however, unclear whether a previous HIV diagnosis results in earlier initiation of ANC. We estimated the probability of early ANC initiation among women with a previous HIV-positive diagnosis compared to those who first tested for HIV during ANC and explored determinants of early ANC among HIV-positive women. We conducted an analysis of a cross-sectional survey among 411 HIV-positive adult (>18 years) women who gave birth at midwife obstetrics units in Gauteng between October 2016 and May 2017. Predictors of early ANC (defined as initiating ANC before or at 14 weeks of gestation) were assessed by multivariate log-binomial regression model. Overall, 51% (210) were diagnosed during pregnancy with 89% (188) initiating antiretroviral therapy on the same day of diagnosis. There was no meaningful difference in the timing of ANC initiation between women with previous HIV diagnosis [adjusted risk ratio (aRR) = 1.2; 95% confidence interval (95% CI): 0.9-1.7] compared with those diagnosed during pregnancy. Early ANC was predicted by planned pregnancy [aRR = 1.3; 95% CI: 1.1-1.7], parity (>2 children) [aRR = 0.6; 95% CI: 0.2-0.9] compared to not having a child, and tuberculosis diagnosis [aRR = 2.9; 95% CI: 1.4-6.1]. Our results suggest the need for a targeted intervention among HIV-positive women by improving the quality, content and outreach of ANC services to enhance early ANC uptake, and minimize mother-to-child transmission risk.

Objective: To explore stillbirth risk across gestation in three provinces of South Africa with different antenatal care schedules., Design: Retrospective audit of perinatal death data using South Africa's Perinatal Problem Identification Programme., Setting: In 2008, the Basic Antenatal Care Programme was introduced in Limpopo and Mpumalanga provinces, reducing appointments to five visits at booking, 20, 26, 32, 38 weeks and 41 weeks if required. In the Western Cape province seven appointments remained at booking, 20, 26, 32, 34, 36, 38 and 41 weeks if required., Population: All audited stillbirths (n = 4211) between October 2013 to August 2015 in Limpopo, Mpumalanga and Western Cape., Methods: Stillbirth risk (26-42 weeks of gestation, >1000 g) across gestation was calculated using Yudkin's method. Stillbirth risk was compared between provinces and relative risks were calculated between Limpopo/ Mpumalanga and Western Cape., Main Outcome Measures: Stillbirth risk across gestation., Results: Stillbirth risk peaked at 38 weeks of gestation in Limpopo (relative risk [RR] 3.11, 95% CI 2.40-4.03, P < 0.001)and Mpumalanga (RR 3.09, 95% CI 2.37-4.02, P < 0.001) compared with Western Cape, where no peak was observed. Stillbirth risk at 38 weeks gestation in Limpopo and Mpumalanga were statistically greater than both the 37 and 39 weeks gestation within provinces (P < 0.001). As expected, a peak at 41 weeks of gestation was observed in all provinces., Conclusions: The increased period of stillbirth risk occurs after a 6-week absence of antenatal care. This calls for a refocus on the impact of reduced antenatal care visits during the third trimester., Tweetable Abstract: Reduced antenatal care in the third trimester may increase stillbirth risk., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Background: Intimate partner violence (IPV) during or before pregnancy is associated with many adverse health outcomes. Pregnancy-related complications or poor infant health outcomes can arise from direct trauma as well as physiological effects of stress, both of which impact maternal health and fetal growth and development. Antenatal care can be a key entry point within the health system for many women, particularly in low-resource settings. Interventions to identify violence during pregnancy and offer women support and counselling may reduce the occurrence of violence and mitigate its consequences., Methods: Following a formative research phase, a randomized controlled trial will be conducted to test a nurse-led empowerment counselling intervention, originally developed for high-income settings and adapted for urban South Africa. The primary outcome is reduction of partner violence, and secondary outcomes include improvement in women's mental health, safety and self-efficacy. The study aims to recruit 504 pregnant women from three antenatal clinics in Johannesburg who will be randomized to the nurse-led empowerment arm (two 30-min counselling sessions) or enhanced control condition (a referral list) to determine whether participants in the intervention arm have better outcomes as compared to the those in the control arm., Discussion: This research will provide much needed evidence on whether a short counselling intervention delivered by nurses is efficacious and feasible in low resource settings that have high prevalence of IPV and HIV., Trial Registration: The study was registered in the South African Clinical Trials Registry (DOH-27-0414-4720) on 11 August 2014 and in the ISRCTN Registry ( ISRCTN35969343 ) on 23 May 2016).

Aim: The aim of the study was to investigate the challenges experienced by midwives during the implementation of the Basic Antenatal Care programme., Background: The National Department of Health recommended that all primary health care facilities in South Africa start to implement the Basic Antenatal Care programme by the end of 2008. In her work as coordinator of the Maternal Child and Women's Health programme for the eThekwini Municipality, the researcher observed the slow progress in implementation of the programme in the eThekwini district., Method: A descriptive qualitative design using questionnaires was used to assess the challenges being experienced by midwives during the implementation of the programme., Results: The challenges identified included: shortage of staff, lack of cooperation from referral hospitals, lack of in-service training, problems with transportation of specimens to laboratories, lack of material resources, unavailability of Basic Antenatal Care programme guidelines and lack of management support., Conclusion: The challenges were the possible cause of the slow progress in the implementation of the programme., Implications for Nursing Management: The successful implementation of the new programme is dependent on support and guidance offered by the nurse manager to the staff at operational level. The manager should monitor and develop strategies to address and overcome challenges that hinder implementation of the Basic Antenatal Care programme., (© 2013 John Wiley & Sons Ltd.)

Introduction: Detecting the risk of stillbirth during pregnancy remains a challenge. Continuous-wave Doppler ultrasound (CWDU) can be used to screen for placental insufficiency, which is a major cause of stillbirths in low-risk pregnant women. This paper describes the adaptation and implementation of screening with CWDU and shares critical lessons for further rollout. Screening of 7088 low-risk pregnant women with Umbiflow™ (a CWDU device) was conducted in 19 antenatal care clinics at nine study sites in South Africa. Each site comprised a catchment area with a regional referral hospital and primary healthcare antenatal clinics. Women with suspected placental insufficiency as detected by CWDU were referred for follow-up at the hospital. A 35–43% reduction in stillbirths was recorded. Methods: The authors followed an iterative reflection process using the field and meeting notes to arrive at an interpretation of the important lessons for future implementation of new devices in resource-constrained settings. Results: Key features of the implementation of CWDU screening in pregnancy combined with high-risk follow-up are described according to a six-stage change framework: create awareness; commit to implement; prepare to implement; implement; integrate into routine practice; and sustain practice. Differences and similarities in implementation between the different study sites are explored. Important lessons include stakeholder involvement and communication and identifying what would be needed to integrate screening with CWDU into routine antenatal care. A flexible implementation model with four components is proposed for the further rollout of CWDU screening. Conclusions: This study demonstrated that the integration of CWDU screening into routine antenatal care, combined with standard treatment protocols at a higher-level referral hospital, can be achieved with the necessary resources and available maternal and neonatal facilities. Lessons from this study could contribute to future scale-up efforts and help to inform decisions on improving antenatal care and pregnancy outcomes in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

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Background: Many women in sub-Saharan Africa initiate antenatal care (ANC) late in pregnancy, undermining optimal prevention of mother-to-child-transmission (PMTCT) of HIV. Questions remain about whether and how late initiation of ANC in pregnancy is related to adherence to antiretroviral therapy (ART) in the era of national dolutegravir roll-out. Methods: This study employed a qualitative design involving individual interviews and focus group discussions conducted between August 2018 and March 2019. We interviewed 37 pregnant and lactating women living with HIV selected purposively for early or late presentation to ANC from poor urban communities in South Africa and Uganda. Additionally, we carried out seven focused group discussions involving 67 participants in both countries. Data were analysed thematically in NVivo12. Results: Women described common underlying factors influencing both late ANC initiation and poor ART adherence in South Africa and Uganda. These included poverty and time constraints; inadequate health knowledge; perceived low health risk; stigma of HIV in pregnancy; lack of disclosure; and negative provider attitudes. Most late ANC presenters reported relationship problems, lack of autonomy and the limited ability to dialogue with their partners to influence household decisions on health and resource allocation. Perception of poor privacy and confidentiality in maternity clinics was rife among women in both study settings and compounded risks associated with early disclosure of pregnancy and HIV. Women who initiated ANC late and were then diagnosed with HIV appeared to be more susceptible to poor ART adherence. They were often reprimanded by health workers for presenting late which hampered their participation in treatment counselling and festered provider mistrust and subsequent disengagement in care. Positive HIV diagnosis in late pregnancy complicated women's ability to disclose their status to significant others which deprived them of essential social support for treatment adherence. Further, it appeared to adversely affect women's mental health and treatment knowledge and self-efficacy. Conclusions: We found clear links between late initiation of ANC and the potential for poor adherence to ART based on common structural barriers shaping both health seeking behaviours, and the adverse impact of late HIV diagnosis on women's mental health and treatment knowledge and efficacy. Women who present late are a potential target group for better access to antiretrovirals that are easy to take and decrease viral load rapidly, and counselling support with adherence and partner disclosure. A combination of strengthened health literacy, economic empowerment, improved privacy and patient-provider relationships as well as community interventions that tackle inimical cultural practices on pregnancy and unfair gender norms may be required. [ABSTRACT FROM AUTHOR]

Background: In South Africa (SA), approximately 16 000 stillbirths occur annually. Most are classified as unexplained and occur in district hospitals. Many of these deaths may be caused by undetected foetal growth restriction. Continuous wave Doppler ultrasound of the umbilical artery (CWDU-UmA) is a simple method for assessing placental function. This screening method may detect the foetus at risk of dying and growth-restricted foetuses, allowing for appropriate management. Methods: A cohort study was conducted across South Africa. Pregnant women attending primary health care clinics at 28--34 weeks gestation were screened using CWDU-UmA. Women not screened at those antenatal clinics served as control group 1. Control group 2 consisted of the subset of control group 1 with women detected with antenatal complications excluded. Women with foetuses identified with an abnormal CWDU-UmA test were referred and managed according to a standardised protocol. A comparison between the study and control groups was performed. Results: The study group consisted of 6536 pregnancies, and there were 66 stillbirths (stillbirth rate [SBR]: 10.1/1000 births). In control group 1, there were 193 stillbirths in 10 832 women (SBR: 17.8/1000 births), and in control group 2, 152 stillbirths in 9811 women (SBR: 15.5/1000 births) (risk ratio: 0.57, 95% confidence intervals: 0.29--0.85 and 0.65, 0.36--0.94, respectively). Conclusion: Screening a low-risk pregnant population identified the low-risk mother with a high-risk foetus, and acting on the information as described was associated with a significant reduction (35% -- 43%) in stillbirths. This demonstrates a step-change reduction in stillbirths and warrants screening in SA. [ABSTRACT FROM AUTHOR]

Background: Sexually transmitted infections (STIs) during pregnancy are associated with adverse birth outcomes, including preterm birth, low birth weight, perinatal death, and congenital infections such as increased mother-to-child HIV transmission. Prevalence of STIs among pregnant women in South Africa remains high, with most women being asymptomatic for their infection(s). Unfortunately, most STIs remain undetected and untreated due to standard practice syndromic management in accordance with World Health Organization (WHO) guidelines. Although lab-based and point-of-care molecular tests are available, optimal screening strategies during pregnancy, their health impact, and cost-effectiveness are unknown.Methods: We will implement a 3-arm (1:1:1) type-1 hybrid effectiveness-implementation randomized-controlled trial (RCT). We will enroll 2500 pregnant women attending their first antenatal care (ANC) visit for their current pregnancy at participating health facilities in Buffalo City Metro District, Eastern Cape Province, South Africa. Participants allocated to arms 1 and 2 (intervention) will receive GeneXpert® point-of-care diagnostic testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, with same-day treatment for detected infection(s). Arm 1 will additionally receive a test-of-cure 3 weeks post-treatment, while Arm 2 will receive a repeat test at 30-34 weeks' gestation. Those allocated to Arm 3 will receive syndromic management (standard-of-care). The RE-AIM framework will be used to guide collection of implementation indicators to inform potential future scale up. Primary outcome measures include (1) frequency of adverse birth outcomes among study arms, defined by a composite measure of low birth weight and pre-term delivery, and (2) change in STI prevalence between baseline and birth outcome among intervention arms and compared to standard-of-care. Estimates and comparative costs of the different screening strategies relative to standard-of-care and the costs of managing adverse birth outcomes will be calculated. Cost-effectiveness will be assessed per STI and disability-adjusted life year averted.Discussion: This trial is the first RCT designed to identify optimal, cost-effective screening strategies that decrease the burden of STIs during pregnancy and reduce adverse birth outcomes. Demonstrating the impact of diagnostic screening and treatment, compared to syndromic management, on birth outcomes will provide critical evidence to inform changes to WHO guidelines for syndromic management of STIs during pregnancy.Trial Registration: ClinicalTrials.gov NCT04446611 . Registered on 25 June 2020. [ABSTRACT FROM AUTHOR]

Background: We evaluated continuous quality improvement (CQI) targeting antenatal HIV care quality in rural South Africa using a stepped-wedge cluster-randomised controlled trial (Management and Optimisation of Nutrition, Antenatal, Reproductive, Child health, MONARCH) and an embedded process evaluation. Here, we present results of the process evaluation examining determinants of CQI practice and 'normalisation.' Methods: A team of CQI mentors supported public-sector health workers in seven primary care clinics to (1) identify root causes of poor HIV viral load (VL) monitoring among pregnant women living with HIV and repeat HIV testing among pregnant women not living with HIV, and (2) design and iteratively test their own solutions. We used a mixed methods evaluation with field notes from CQI mentors ('dose' and 'reach' of CQI, causes of poor HIV care testing rates, implemented change ideas); patient medical records (HIV care testing by clinic and time step); and semi-structured interviews with available health workers. We analysed field notes and semi-structured interviews for determinants of CQI implementation and 'normalisation' using Normalisation Process Theory (NPT) and Tailored Implementation of Chronic Diseases (TICD) frameworks. Results: All interviewed health workers found the CQI mentors and methodology helpful for quality improvement. Total administered 'dose' was higher than planned but 'reach' was limited by resource constraints, particularly staffing shortages. Simple workable improvements to identified root causes were implemented, such as a patient tracking notebook and results filing system. VL monitoring improved over time, but not repeat HIV testing. Besides resource constraints, gaps in knowledge of guidelines, lack of leadership, poor clinical documentation, and data quality gaps reduced CQI implementation fidelity and normalisation. Conclusion: While CQI holds promise, we identified several health system challenges. Priorities for policy makers include improving staffing and strategies to improve clinical documentation. Additional support with implementing clinical guidelines and improving routine data quality are needed. Normalising CQI may be challenging without concurrent health system improvements. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality among adolescent mothers in South Africa is higher than many middle-income countries. This is largely attributable to conditions that can be prevented or managed by high quality antenatal care. The way in which pregnant adolescents are treated at antenatal clinics influences their timely utilization of antenatal services. This qualitative study reports on the experiences of pregnant adolescents with health care workers when accessing antenatal care. Methods: Pregnant girls aged 13–19 (n = 19) who attended public health care facilities that provide Basic Antenatal Care (BANC) services in Cape Town, South Africa were recruited. Four face to face in-depth interviews and four mini focus group discussions were undertaken, facilitated by a topic guide. Thematic analyses were used to analyse the data. Results: Experiences that reinforce antenatal attendance, such as respectful and supportive treatment, were outweighed by negative experiences, such as victimization; discrimination against being pregnant at a young age; experiencing disregard and exclusion; inadequate provision of information about pregnancy, health and childbirth; clinic attendance discouragement; and mental health turmoil. Conclusions: There is evidence of a discordant relationship between the health care workers and the pregnant adolescents. Adolescents feel mistreated and discriminated against by the health care workers, which in turn discourages their attendance at antenatal clinics. Maternal health care workers need to receive support and regular training on the provision of youth friendly antenatal care and be regularly evaluated, to promote the provision of fair and high quality antenatal services for adolescent girls. Plain language summary: Antenatal care is the routine health care of pregnant women in order to diagnose pregnancy complications and to provide information about lifestyle, pregnancy and delivery. Maternal deaths among teenage mothers in South Africa is high and is largely due to conditions that can be prevented or managed by high quality antenatal care. Timely and routine antenatal care is therefore crucial for pregnant teenagers. The way in which pregnant teenagers are treated by health care workers at antenatal clinics influences their clinic attendance. This study reports on the experiences of pregnant teenagers with health care workers, when accessing antenatal care in Cape Town, South Africa. Nineteen pregnant girls aged 13–19 years were interviewed. Some positive experiences such as respectful and supportive treatment were reported. However, more negative experiences were reported, including victimization; discrimination against being pregnant at a young age; feeling disregarded and excluded; a lack of information about pregnancy, health and childbirth; being discouraged from attending the clinics; and mental health distress. In conclusion, many teenagers felt mistreated and discriminated against by the health care workers, which discouraged their clinic attendance. Maternal health care workers in South Africa need to receive support and regular training to provide youth friendly antenatal care to teenage girls. [ABSTRACT FROM AUTHOR]

In this paper, we outline a critical reparative justice/care approach to adolescent reproductive health as an alternative to the standard public health response to 'teenage pregnancy'. Joining an increasing body of critical scholarship that calls for nuance in understanding reproduction amongst young people, we draw, in this paper, on data generated from an ethnographic study conducted in antenatal care units in an Eastern Cape township in South Africa. To illustrate the approach we propose, we home in on five case studies that highlight the variability of young women's lives, the multiple injustices they experience, and the agency they demonstrate in negotiating their way through pregnancy and birth. Injustices evident in these cases centre on sexual violence, rape myths, education system failures, health system failures, shaming and stigmatising practices, socio-economic precariousness, absent male partners, and denial of services. We outline how the reparative justice approach that highlights repair and support for social and health injustices at the individual and collective level as well as at the material and symbolic level may be taken up to ensure reproductive justice for young pregnant women. [ABSTRACT FROM AUTHOR]

Background: The quality of the decisions made by women during pregnancy, especially their first visit, depends on their health needs, their health-seeking behaviour and the type of information available to them. Aim: This study describes the health education needs, information barriers and health information-seeking behaviour of pregnant women on their first visit to antenatal clinics in a low-income setting in the Western Cape. Setting: The setting was two antenatal facilities in Khayelitsha Health District facilities in South Africa. Methods: A quantitative descriptive survey was conducted. A systematic random sample of 261 antenatal first visit attendees between May and July 2016 was selected. Data were collected using a researcher-administered questionnaire and was analysed using descriptive statistics, 95% confidence intervals and non-parametric tests. Results: The response rate of the study was 92% (n = 240). Pregnant women attending an antenatal clinic for the first time reported high information needs with low health informationseeking behaviours and high information barriers. Doctors, nurses (2.2, ±1.0), family and friends (2.0, ±0.6) were the most frequently used sources of health information, while watching television or listening to the radio (1.5, ±0.9) were the least used sources of health information. Having a medical diagnosis ( p < 0.001) and being of an advanced maternal age ( p = 0.005) were predictive of higher health-seeking behaviour. The reliance on passively receiving information from health sources may indicate low levels of health literacy and its inverse relationship to health promoting behaviours which should be the subject of further investigation. [ABSTRACT FROM AUTHOR]

Background: Seasonality of food availability, physical activity, and infections commonly occurs within rural communities in low and middle-income countries with distinct rainy seasons. To better understand the implications of these regularly occurring environmental stressors for maternal and child health, this study examined seasonal variation in nutrition and health care access of pregnant women and infants in rural South Africa. Methods: We analyzed data from the Venda Health Examination of Mothers, Babies and their Environment (VHEMBE) birth cohort study of 752 mother-infant pairs recruited at delivery from August 2012 to December 2013 in the Vhembe District of Limpopo Province, the northernmost region of South Africa. We used truncated Fourier series regression to assess seasonality of antenatal care (ANC) attendance, dietary intake, and birth size. We additionally regressed ANC attendance on daily rainfall values. Models included adjustment for sociodemographic characteristics. Results: Maternal ANC attendance, dietary composition, and infant birth size exhibited significant seasonal variation in both unadjusted and adjusted analyses. Adequate frequency of ANC attendance during pregnancy (≥ 4 visits) was highest among women delivering during the gardening season and lowest during the lean (rainy) season. High rainfall during the third trimester was also negatively associated with adequate ANC attendance (adjusted OR = 0.59, 95% CI: 0.40, 0.86). Carbohydrate intake declined during the harvest season and increased during the vegetable gardening and lean seasons, while fat intake followed the opposite trend. Infant birth weight, length, and head circumference z-scores peaked following the gardening season and were lowest after the harvest season. Maternal protein intake and ANC ≤ 12 weeks did not significantly vary by season or rainfall. Conclusions: Seasonal patterns were apparent in ANC utilization, dietary intake, and fetal growth in rural South Africa. Interventions to promote maternal and child health in similar settings should consider seasonal factors. [ABSTRACT FROM AUTHOR]

Background: The Sub-Saharan Africa region still remains the epicentre of the global HIV/AIDS epidemic. With regards to new paediatric HIV infections, almost 90% of new HIV infections are among children (aged 0–14 years), largely through mother to child transmission. Male Partner Involvement in Prevention of Mother to Child Transmission programmes is now strongly advocated as being key in improving infant outcomes. This study describes the role of Male Partner Involvement on infant HIV infection and mortality survival in the first year among HIV-exposed infants born from HIV positive mothers. Methods: This study was a two-phase, two condition (intervention or control) longitudinal study as part of a clinic-randomized Prevention of Mother to Child Transmission controlled trial. For Phase 1, female participants were recruited without their male partners. In Phase 2, both female and male participants were enrolled in the study as couples in order to encourage active Male Partner Involvement during pregnancy. Participants had two assessments prenatally (8–24 weeks and 32 weeks) and three assessments postnatally (6 weeks, 6 months, and 12 months) Results: About 1424 women were eligible for recruitment into the study and 18 eligible women declined to participate. All women had a partner; 54% were unmarried, 26% were cohabiting, and 20% were married. Just over half (55%) of the women had been diagnosed with HIV during the current pregnancy. Phase 1 had significantly more HIV-infected infants than Phase 2 at 12-months postpartum (aOR = 4.55 [1.38, 15.07]). Increased depressive symptoms were associated with infant HIV infection at 12-months (aOR = 1.06 [1.01, 1.10]). Phase 1 also had a significantly greater proportion of dead and HIV-infected infants than Phase 2 at 12-months (aOR = 1.98 [1.33, 2.94]). Conclusion: Male partner involvement in antenatal care is critical in ensuring infant survival and HIV infection among children born to HIV-positive mothers. This study highlights the high risk of ante-and-post natal depression and underscores the need of screening for depression during pregnancy. Trial registration: ClinicalTrials.Gov; Trial Number . [ABSTRACT FROM AUTHOR]

Background: Postpartum depression (PPD) is a common mental health condition that can compromise the quality of life and functional capacity of mothers and cause health and developmental problems in children born to affected mothers. Objectives: We set out to measure the prevalence of PPD comparing postpartum HIV-1 infected women with pre-pregnancy HIV care experience, newly diagnosed (in latest pregnancy) HIV-1 infected women and HIV negative women, and to identify predictors of major PPD among these women in a peri-urban clinic in South Africa. Methods: We conducted a cross-sectional survey of 1151 adult (≥18 years) postpartum HIV-1 infected (690) and HIV negative (461) women who delivered up to 30 days before study enrolment, interviewed after their first post-natal visit (3–6 days post- delivery) at Midwife Obstetric Units in Gauteng, South Africa. PPD was categorised into no depression (CES-D 10 total score <5), low to medium depression (CES-D 10 total score ≥5 and <10) and major depressive symptoms (CES-D 10 total score≥10). We used ordered logistic regression to identify predictors of postpartum depression and report adjusted odds ratio (aOR) and 95% confidence intervals (CIs). Results: Overall 288 (25.0%) women screened positive for postpartum depression, a total of 168 (14.6%) women had low to medium PPD and 120 (10.4%) had major PPD. A higher proportion of HIV negative women experienced PPD, 129/461 (28.0%) among HIV negative vs. 159/690 (23.0%) among HIV-1 infected. Among HIV positive women, there was no meaningful difference in PPD between newly HIV diagnosed and those diagnosed before the most recent pregnancy (aOR 1.3, 95% confidence interval (CI): 0.9–1.8). Predictors of PPD among HIV positive women were living with friends/in a house-share (aOR 0.5 for house-share vs. own home, 95% CI: 0.3–0.9), and attending antenatal care (ANC) for the most recent pregnancy (aOR 0.2 for ANC attendance vs. no ANC attendance, 95% CI: 0.0–0.5). Living with friends/in a house-share was also a predictor of PPD among HIV negative women (aOR 0.4 for house-share vs. own home, 95% CI: 0.2–0.8). Conclusions and recommendations: Targeted symptom screening based on identified risk factors should be considered for postpartum women to increase PPD case-finding and referral to specialised social support services. [ABSTRACT FROM AUTHOR]

This study aimed to assess the longitudinal prevalence of prenatal and postnatal depression and associated factors among HIV-infected women in rural South Africa. In a longitudinal, cluster-randomized, prevention of mother to child transmission (PMTCT) intervention trial, 681 HIV-infected prenatal women in 12 community health centres in Mpumalanga province, South Africa, were recruited in 2015 by consecutive sampling at 8-24 weeks pregnancy and followed up at 32 weeks prenatally, and 6 and 12 months postpartum (retention rate = 59.2%). Results indicate that at baseline, 48.7% of the women screened positive for depression (scores of ≥13 on the “Edinburgh Postnatal Depression Scale 10”), while postnatally (at 12 months) the prevalence was 35.6%. Mothers who did not have depression before or after were 205 (50.1%), those who had depression before and after were 58 (14.4%), those who had depression only before were 81 (20.1%), and those who had depression only after were 59 (14.6%). In multinominal logistic regression analyses, less education and physical and psychological intimate partner violence were associated with sustained perinatal depression. Participation in the PMTCT intervention was associated with remitting depression while alcohol use was associated with the onset of postnatal depression. Using generalized linear mixed models in longitudinal analyses, psychological partner violence, lack of male involvement during pregnancy and non-adherence to antiretroviral treatment were associated with depression. In conclusion, a high pre- and postnatal prevalence of depression was found highlighting the utility of interventions to address prevention and treatment of perinatal depression. [ABSTRACT FROM AUTHOR]

Background: The current COVID-19 pandemic caused by the SARS-CoV-2 virus has reached the stage of community spread in South Africa. Asymptomatic carriers have been reported amongst pregnant women. Against this background, a strategy of universal testing of all patients visiting facilities for antenatal care should be considered, as this information will allow proper planning of obstetric services as well as reducing risk to health care workers and patients. Methods: Asymptomatic pregnant women visiting Kalafong Provincial Tertiary Hospital in Atteridgeville, Pretoria, for antenatal care were randomly selected for SARS-CoV-2 PCR testing. Results: We report the results of the fi rst 67 patients who were tested. Their mean age was 33.3 years (SD = 6.44), and 34.3% were HIV infected. Sixteen patients (32.8%) had comorbidities such as diabetes mellites type II/gestational diabetes and hypertension. All 67 women tested negative for SARS-CoV-2 infection. Conclusion: The asymptomatic carrier status at this point in time is still zero, refl ecting the early stage of the epidemic in Tshawane at the time of tesing. Universal testing of this group of patients should continue, as early identifi cation of asymptomatic carriers in pregnant women is essential for the provision of safe obstetric care, especially against the background of the presence of signifi cant comorbities in this population group. [ABSTRACT FROM AUTHOR]

Objective: To explore stillbirth risk across gestation in three provinces of South Africa with different antenatal care schedules.Design: Retrospective audit of perinatal death data using South Africa's Perinatal Problem Identification Programme.Setting: In 2008, the Basic Antenatal Care Programme was introduced in Limpopo and Mpumalanga provinces, reducing appointments to five visits at booking, 20, 26, 32, 38 weeks and 41 weeks if required. In the Western Cape province seven appointments remained at booking, 20, 26, 32, 34, 36, 38 and 41 weeks if required.Population: All audited stillbirths (n = 4211) between October 2013 to August 2015 in Limpopo, Mpumalanga and Western Cape.Methods: Stillbirth risk (26-42 weeks of gestation, >1000 g) across gestation was calculated using Yudkin's method. Stillbirth risk was compared between provinces and relative risks were calculated between Limpopo/ Mpumalanga and Western Cape.Main Outcome Measures: Stillbirth risk across gestation.Results: Stillbirth risk peaked at 38 weeks of gestation in Limpopo (relative risk [RR] 3.11, 95% CI 2.40-4.03, P < 0.001)and Mpumalanga (RR 3.09, 95% CI 2.37-4.02, P < 0.001) compared with Western Cape, where no peak was observed. Stillbirth risk at 38 weeks gestation in Limpopo and Mpumalanga were statistically greater than both the 37 and 39 weeks gestation within provinces (P < 0.001). As expected, a peak at 41 weeks of gestation was observed in all provinces.Conclusions: The increased period of stillbirth risk occurs after a 6-week absence of antenatal care. This calls for a refocus on the impact of reduced antenatal care visits during the third trimester.Tweetable Abstract: Reduced antenatal care in the third trimester may increase stillbirth risk. [ABSTRACT FROM AUTHOR]

Background: Pregnancy among adolescents in South Africa is a growing concern as it may be associated with adverse socio-economic and health impacts. Timeous initiation and optimal utilisation of antenatal care (ANC) services is imperative to ensure positive pregnancy outcomes. However, this is not always possible owing to various challenges. Methods: A multi-method study design using both retrospective record review and qualitative interviews was undertaken at a district hospital on the North Coast of KwaZulu-Natal, South Africa. Data on ANC attendance trends and obstetric/perinatal outcomes for all recorded adolescent pregnancies (13–16 years) at the district hospital under study was collected over 3 years (2011–2013) (n= 314). Qualitative interviews with randomly selected pregnant adolescents were conducted to assess experiences of ANC access and utilisation. Results: Late ANC booking and reduced ANC visits were common for adolescent pregnancies. Under-utilisation of ANC (i.e. less than 4 visits) was significantly associated with lower gestational age (< 37 weeks) (OR = 2.64; 95% CI = 1.04; 6.74;p< 0.05). Low birthweight, low Apgar scores as well as the incidence of maternal anaemia and pregnancy-induced hypertension (PIH) were found to be related to late ANC booking. In-depth interviews suggested that teenagers suffered emotional vulnerability linked to family, partner and financial support. They discussed various barriers linked with accessing ANC while acknowledging perceived benefits. Conclusion: Adolescent pregnancy was associated with late booking and reduced ANC visits, which was a risk for adverse maternal health outcomes. In-depth interviews suggested numerous challenges associated with ANC access including; financial barriers, attitude of healthcare workers (HCWs), long queues, distance travelled to access ANC services, human immunodeficiency virus (HIV) status and a lack of knowledge. [ABSTRACT FROM PUBLISHER]

Background: Late booking and infrequent antenatal care (ANC) are common but avoidable patient-related risk factors for maternal deaths in South Africa. The aim of the study was to examine the association of psychosocial factors with early initiation of ANC and adequate frequency of attendance of ANC clinics among women in an urban and rural location in South Africa.Methods: Data from a 2006 cross-sectional household survey of 363 women from the rural Western Cape and 466 women from urban Gauteng provinces of South Africa for risk of alcohol-exposed pregnancy were analysed. We examined associations between psychosocial variables (self-esteem, cultural influences, religiosity, social capital, social support, pregnancy desire (wanted versus unwanted pregnancy), partner characteristics and mental health) and both early ANC first visit (before 16 weeks) and adequate frequency of ANC visits (4 or more visits) for respondents' last pregnancy.Results: Overall prevalence among urban women of early ANC initiation was 46% and 84% for adequate ANC frequency. Overall prevalence among rural women of early ANC initiation was 45% and 78% for adequate ANC frequency. After adjusting for clustering, psychosocial factors associated with early ANC initiation in the urban site were being employed (OR 1.6; 95% CI 1.0-2.5) and wanted pregnancy (OR 1.8; 95% CI 1.1-3.0). For the rural site, early ANC initiation was significantly associated with being married (OR 1.93; 95% CI 1.0-3.6) but inversely associated with high religiosity (OR 0.5; 95% CI 0.3-0.8). Adequate frequency of ANC attendance in the rural site was associated with wanted pregnancy (OR 4.2; 95% CI 1.9-9.3) and the father of the child being present in the respondent's life (OR 3.0; 95% CI 1.0-9.0) but inversely associated with having a previous miscarriage (OR 0.4; 95% CI 0.2-0.8). There were no significant associations between adequate ANC attendance and the psychosocial factors in the urban site.Conclusion: The majority of women from both sites attended ANC frequently but less than 50% initiated ANC before the recommended 16 weeks gestational age. Interventions to reduce prevalence of late ANC booking and inadequate ANC attendance should engage religious leaders, address unintended pregnancy through family planning education and involve male partners in women's reproductive health. [ABSTRACT FROM AUTHOR]

Background: Decision making is integral to genetic counselling and the premise is that autonomous decisions emerge if patients are provided with information in a non‐directive manner. The pivotal activity in antenatal diagnosis counselling with at‐risk pregnant women is decision making regarding invasive procedures. This process is not well understood in multicultural settings. Objective: This study examined multicultural genetic counselling interactions with women of advanced maternal age (AMA). It aimed to investigate the participants' orientation towards the amniocentesis decision. Design: Data were collected during 14 video‐recorded consultations between six genetic counsellors and 14 women of AMA in a genetic counselling clinic in South Africa. The design was qualitative and conversation analysis was used for analysis. Results: Analysis revealed that counsellors used several strategies to facilitate discussions and decision making. However, the invitation to make a decision regarding amniocentesis was not perceived as being neutral. Both the counsellors and the women appeared to treat the offer as one which should be accepted. This resulted in a paradox, as strategies intended to allow neutral discussion seem to achieve the opposite. It is suggested that these results may be linked to the local health‐care setting. Conclusion: The results suggest that the understanding of decision‐making processes and enhancing autonomy may require a more detailed investigation into psychosocial, political and historical factors in the local health‐care setting. Models of practice as well as the training of genetic counsellors need to be sensitive to these influences. A closer examination of interactional variables may yield new and relevant insights for the profession. [ABSTRACT FROM AUTHOR]

Globally, approximately 70% of pregnant mothers access Antenatal Care (ANC) at least once during pregnancy. In South Africa (SA), approximately 95% - 97% of pregnant mothers attend ANC although majority present late after 20 weeks of pregnancy and some may have only one visit due to various factors. The purpose of this study was to assess behavioural factors associated with late presentation at ANC in Limpopo Province, SA. A qualitative, exploratory approach was used. Population comprised of pregnant mothers who were attending ANC at Primary Health Care (PHC) facilities. Non-probability, purposive sampling method was used to sample 40 pregnant mothers. Data were collected using Focus Group Discussions (FGDs). Data were analysed qualitatively through open coding method. Findings revealed that knowledge deficiency related to Basic Antenatal Care (BANC), advanced maternal age of 40 years and above feel ashamed of pregnancy, ignorance and laziness of pregnant mothers to attend ANC services and unhealthy lifestyle such as abuse of alcohol were associated with late presentation at ANC. There is a need to develop an intervention programme to increase pregnancy awareness among mothers of child bearing age. [ABSTRACT FROM AUTHOR]

Aims: The aim of the study is to investigate the influence of maternal education on the utilization of maternal health care services in selected areas of the Eastern Cape. Moreover, the study’s aim also is to examine the reasons for non-use as well as determinants and levels of maternal health care utilization. Methods: From the 422 participants sampled, 345 fully completed questionnaires were returned and included in the analysis. The study used multilevel analyses. The dependent variables included antenatal care, delivery care, and postnatal care within 2 months after birth. The independent variables were socioeconomic and demographic factors selected based on literature on the subject. Results: Use of antenatal and delivery care services was high in the study areas, but postnatal check-ups were reported below 50%. The majority of the women (50%) reported that the ambulance arrived too late, and, as such, they did not use health facilities when giving birth. Women with four or more children use antenatal and delivery care less than women with one child, while women with four or more children use postnatal care more than women with just one child. Conclusions: This study will be immense useful for the policy-makers, public health research managers and concerned health care decision-makers. [ABSTRACT FROM AUTHOR]

South Africa has instituted various strategies to enhance antenatal care services, in an attempt to address the country's high maternal and perinatal mortality rates. The National Department of Health ordered all primary healthcare facilities to adopt the basic antenatal care (BANC) approach by the end of 2008. Some facilities started implementing the BANC approach but failed to sustain it. This study was conducted in the eThekwini municipality, targeting facilities that had successfully implemented the basic antenatal care approach. The aim of the study was to assess the knowledge and perceptions of midwives regarding this approach. Questionnaires were completed by 59 midwives. The Kruskal Wallis test indicated that midwives' knowledge and perceptions differed according to age, gender, race and years of experience but no significant differences were found. Midwives with positive perceptions and a good understanding of the basic antenatal care approach contributed to its successful implementation. [ABSTRACT FROM AUTHOR]

To assess women's experience of public antenatal care (ANC) services and reasons for late antenatal care attendance in inner-city Johannesburg, South Africa. This cross-sectional study was conducted at three public labour wards in Johannesburg. Interviews were conducted with 208 women who had a live-birth in October 2009. Women were interviewed in the labour wards post-delivery about their ANC experience. Gestational age at first clinic visit was compared to gestational age at booking (ANC service provided). ANC attendance was high (97.0 %) with 46.0 % seeking care before 20 weeks gestation (early). Among the 198 women who sought care, 19.2 % were asked to return more than a month later, resulting in a 3-month delay in being booked into the clinic for these women. Additionally 49.0 % of women reported no antenatal screening being conducted when they first sought care at the clinic. Delay in recognizing pregnancy (21.7 %) and lack of time (20.8 %) were among the reasons women gave for late attendance. Clinic booking procedures and delays in diagnosing pregnancy are important factors causing women to access antenatal care late. In a country where a third of pregnant women are HIV infected, early ANC is vital in order to optimise ART initiation and thereby reduce maternal mortality and paediatric HIV infection. It is therefore imperative that existing antenatal care policies are implemented and reinforced and that women are empowered to demand better services. [ABSTRACT FROM AUTHOR]

The research assesses prevention-of-mother-to-child-transmission-of-HIV (PMTCT) services following implementation of programme-strengthening activities in a municipality in the Eastern Cape Province, South Africa. A pre-intervention and post-intervention design was used to conduct facility assessments and client exit interviews at baseline and after 28 months. For the facility assessments, unstructured interviews were conducted with the heads of maternity wards at each delivery facility (n = 4), nurses (n = 9) and lay counsellors (n = 18). District Health Information System (DHIS) records were used to assess changes on PMTCT-programme indicators. Observations were conducted at the fixed clinics and hospitals to determine compliance to the national criteria for PMTCT-services delivery. For the exit interviews with clients, the pre- and post-assessment samples, respectively, included women attending for antenatal care (n = 296; n = 239) as well as HIV-positive women attending for postnatal care (n = 70; n = 142). The personnel generally perceived the PMTCT services as having been strengthened as a result of the initiative and the DHIS records showed positive changes. Client exit interviews revealed significant increases in the numbers of women who: were aware of the PMTCT programme; were tested for HIV during their pregnancy; were aware of VCT before coming to the facility; knew their HIV-test result; and, had helpful pre-HIV-test and/or post-HIV-test counselling experiences. The long waiting periods at the facilities and the relatively short length of the counselling sessions remained a serious concern. Lessons learnt may help with designing strategies to expand the national programme in South Africa as well as PMTCT programmes elsewhere. [ABSTRACT FROM AUTHOR]